First Year Mentor Application

First Year Mentor Application
Which campus or campuses are you applying to mentor at? *

Advantage Academy (Grand Prairie) Avalon High School Ellis County JJAEP School Ennis High School Ferris High School Heritage High School Italy High School Life High School Oak Cliff Maypearl High School Midlothian High School Milford High School Palmer High School Red Oak High School Waxahachie High School Wylie High School (Abilene)
Name *

First Name Middle Name Last Name
Alias(es) if any:
Gender *

Male Female
Residential Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.
Cell Phone Number *
Please enter a valid phone number.
Name/Address of Employer *

Company Name

Street Address

City State / Province

Postal / Zip Code
Does your employer have a charitable giving program (corporate donations, grants, volunteer hour match funds, etc.)

Yes No Unsure
Work Phone Number *
Please enter a valid phone number.
Occupation *
Email *
example@example.com
Please list 3 References (not family members)
First Name*   Last Name*   Email*      Phone Number*
Relationship?   *

First Name*   Last Name*   Email*      Phone Number*
Relationship?   *

First Name*   Last Name*   Email*      Phone Number*
Relationship?   *
Background and History:

If your answer is “Yes” to any of the following questions, then please elaborate in the space provided below.
Have you ever plead guilty or no contest to or otherwise been convicted of driving while intoxicated or driving under the influence, or any other crime other than a traffic violation? *

Yes No
If "Yes", please describe
Do you now have or have you ever had a problem with alcohol, drugs or any other form of addiction? *

Yes No
If "Yes", please describe
Is there any other information about you that might be of relevance to Mentors Care in its consideration that you haven’t otherwise discussed or disclosed in this application? *

Yes No
If "Yes", please describe
Personal Information
1. How did you hear about this program? If someone referred you, who? *
2. What are the greatest strengths (bilingual, previous relevant volunteer experience, etc.) you hope to bring to this program? *
3. Write a brief statement on why you’d like to participate in the mentor program. *
4. What days of the week are you available to volunteer? (check all that apply) *

Monday Tuesday Wednesday Thursday Friday
5. What is the best time for you to volunteer? (check all that apply) *

Morning Afternoon
6. Do you prefer working with a *

Girl Boy No Preference
7. Do you speak a foreign language? *

Yes No
If "Yes", please specify
8. Please list any hobbies or interests you may have *
9. What clubs or groups, if any, do you belong to?
10. Have you worked with high school students before? *

Yes No
If “yes”, in what ways?
11. Have you ever been a mentor in a mentoring program? *

Yes No
If “yes”, please list the years in which you served as a mentor, and the names of the students you’ve mentored.
12. What individual has served as a role model for you? Why? *
Please read and then place your initials beside each of the statements set forth below, evidencing that you’ve read, understand, acknowledge and agree with each statement.
I understand that the mentor program will require that I spend a minimum of one hour with my assigned mentee each week for the academic school year. *
I understand that I will be required to complete the application process and a mentor program training & orientation before I will be assigned a mentee or otherwise allowed to meet with any students served by the organization. *
I understand that I must contact a Mentors Care coordinator if I cannot attend a session with my mentee for any reason, as soon as I realize that I won’t be able to do so. *
I understand although Mentors Care neither prohibits nor condones off-campus visits and meetings between mentors and mentees, inappropriate relationships of any kind between mentors and mentees are absolutely prohibited. Mentors Care will have no duty or liability whatsoever to any mentor who chooses to participate in any such off-campus meetings, in connection with any claims, causes of action, demands, lawsuits, harm or loss of any kind arising from, out of, or in connection with any such off-campus meetings. Mentors are role models for the students they mentor, and should always act in a manner that is reflective of that fact and respectful of the students we serve. *
By my signature below, I represent and warrant that the information I’ve provided in this application is true and correct in all material respects and that I have not omitted or otherwise failed to disclose any information which might be of material relevance to Mentors Care or to its consideration of this application. *

Clear
Date *

Month Day Year
Date
Should be Empty:

First Year Mentor Application

Background and History:

Personal Information

Please read and then place your initials beside each of the statements set forth below, evidencing that you’ve read, understand, acknowledge and agree with each statement.